Vocal process granulomas are traumatic lesions that usually require a combination of factors to form. The most common are excessive or repetitive coughing, prolonged intubation, traumatic intubation, repetitive shouting or screaming. Conditions like laryngopharyngeal reflux or vomiting, smoking and diabetes make these more likely to form. Often eliminating or modifying behavior (strict low-acid diet) allows these to resolve. However, in some cases these can progress. This case is a young female in her 30’s with diabetes who was intubated due to COVID-19. She presented 6 months later with already partial loss of motion to her left vocal fold suggesting progression. Thus, surgery was performed.

Ventricular cysts or saccular cysts are a benign lesions that develop in the laryngeal ventricle, which is the space between the true vocal folds and the false vocal folds. These mucous filled cysts can arise from ductal obstruction of the minor salivary glands or as a result of chronic irritation or vocal overuse. They can be seen in smokers, wind instrument players and glass blowers (any activity that increases pressure and irritation in the larynx). They are similar to, but different from laryngocoeles which are filled with air and communicate with the laryngeal cavity.

Glottic stenosis is narrowing of the airway at the level of the vocal folds. Often this results when bilateral vocal process granulomas progress and form a bridge adjoining the back of both vocal folds. This bridge then tightens slowly with time, until the patient’s airway becomes critically narrowed. Treatment is geared towards airway stabilization often at the expense of a good voice since voice and airway work in opposite directions.

Infraglottic stenosis is a special type of airway stenosis where the narrowing begins at the inferior (undersurface) of the vocal folds. It is most seen from prolonged intubation or in the autoimmune condition called Granulomatosis with Polyangiitis (GPA, formerly known as Wegener’s). This is a case where a highly active marathon runner in her early 40’s reported increasing difficulty breathing while running. Simple reduction of just one side of her stenosis brought her back to nearly baseline.

Several options exist if a patient is found to have a vocal fold paralysis on laryngeal exam. A silastic implant is the best long-term option for a patient especially if the vocal fold closure gap is large. Dr Syamal is one of only a few voice surgeons in the United States that entirely hand-carves voice implants for each and every patient. She utilizes information from your exam, imaging and trigonometric equations to arrive at a completely unique implant size and shape designed just for you! This guarantees the best chance of matching a pre-paralysis voice. This patient was a young singer who had a paralyzed vocal fold from a nerve tumor operation when she was a child as a result her vocal folds could barely touch/close prior to surgery. Note that her vocal folds touch or “close” after the surgery.

When a vocal fold paralysis is new, there is a small chance function may be regained. As such, we usually offer a temporary injection of a filler (hyaluronic acid) to improve the voice while we wait to see if the motion will return. In experienced hands, studies show that hyaluronic acid can last anywhere from 9-12 months. Dr Syamal has had patients where it has lasted even longer.

Source: Bertroche JT, Radder M, Kallogjeri D, Paniello RC, Bradley JP. Patient-defined duration of benefit from juvederm (hyaluronic acid) used in injection laryngoplasty. Laryngoscope. 2019 Dec;129(12):2744-2747. doi: 10.1002/lary.27842. Epub 2019 Jan 30.

A T1 glottic cancer is invasive but vocal fold motion is preserved. It can involve one or both vocal folds as well as the commissures. This case involved both vocal folds and the anterior commissure. Treatment may be surgical or in some cases radiation may be selected due to extent of disease and voice preservation concerns

Laryngeal amyloidosis is a rare condition characterized by the accumulation of amyloid protein deposits in the tissues of the larynx, which can lead to structural changes and disruption of normal function. While laryngeal amyloidosis can occur as a localized disease, it may also be a part of systemic amyloidosis, affecting multiple organs. Diagnosis typically involves a combination of laryngoscopy and biopsy to confirm the presence of amyloid deposits. Treatment aims to alleviate symptoms and may include surgical removal of affected tissues or, in some cases, systemic therapy to address underlying amyloidosis. This patient came to us after another surgeon had already operated on the patient, but the lesion had appeared to grow back. Our surgical intervention led to her diagnosis of amyloidosis. The patient was then referred to an academic center that specialized in treatment of systemic disease.

Laryngeal papilloma is caused by infection with human papillomavirus (HPV), particularly types 6 and 11. These growths can manifest as warty lesions and can occur in both children and adults, with the juvenile form often presenting more aggressively. Symptoms may include hoarseness, a raspy voice, difficulty breathing, and a sensation of a lump in the throat. Depending on their size and location, laryngeal papillomas can obstruct the airway and require treatment. Management often involves surgical removal, which may need to be repeated due to the tendency for recurrence. Regular monitoring is essential to manage symptoms and address any growth of the papillomas. While generally non-cancerous, the presence of these lesions necessitates ongoing evaluation, particularly in high-risk populations.

A glomus tumor or paragangliomas are rare, neuroendocrine tumors that can arise from various structures such as nerves, veins or arteries. This case was a 78-year-old male that presented with a sensation hat there was something in his throat. This is another example of why tracheal examination is key as it revealed the friable red mass in the patient’s trachea. The patient was scheduled for biopsy but it was aborted when Dr Syamal noted that the mass was pulsating. Here is a great example of knowing when to NOT operate. The patient was referred to a larger academic center for further work-up, and embolization.